For inpatient cases, coders are expected to query the physician if there is conflicting information between the medical record final diagnosis and the pathology report. However, if a patient is admitted with a brain mass, the provider notes in the operative report that the mass was removed and the pathology report contains specific information as to the type of tumor (e.g., benign or malignant), can the more specific diagnosis (malignant tumor) be coded based on the pathology report?
The ICD-10-CM Official Guidelines for Coding and Reporting (Section III, B. Abnormal Findings) states, “Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the abnormal finding should be added.”
While it is appropriate to code additional detail regarding the specific site of a femur fracture (e.g., shaft) from an x-ray report, it is not appropriate to code directly from the pathology report. There is a difference in coding the documented clinical diagnosis from the attending physician and coding unconfirmed findings.
When coding strictly from the pathology report, the coder is assigning a diagnosis based on the pathological findings alone without the attending physician’s corroboration. Although the pathologist provides a written interpretation of a tissue biopsy, this is not equivalent to the attending physician’s medical diagnosis based on the patient’s complete clinical picture. The attending physician is responsible for and directly involved in the care and treatment of the patient. This advice is consistent with information regarding appropriateness of code assignments based on documentation by a physician other than the attending physician, since a pathologist’s interpretation of a specimen is not the same as a diagnosis provided by a physician directly involved in the care and treatment of the patient. If the attending physician documented “brain mass” and the pathologist documented “astrocytoma,” this would be conflicting information requiring clarification from the attending physician.
This ensures that the documentation and the codes reported are consistent with the attending physician’s interpretation, since he or she is responsible for the clinical management of the case. It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care of the patient. The plan of care is based on the attending physician’s evaluation, interpretation and collation of all the findings (i.e., pathology, radiology, and laboratory results). This advice is consistent with that previously published in Coding Clinic for ICD-9-CM, and is still applicable for the ICD-10-CM code set.